Falling Through the Cracks

The military struggles to combat the rising suicide rate among Iraq veterans.

His tale is heart-rending. Pvt. Jonathan Schulze, a 25-year-old Marine from Minnesota, hanged himself in January shortly after returning home from Iraq. Schulze had sought help at a Veterans Affairs medical center, but was put on a waiting list, where his name remained when he died.

Schulze's plight is even more tragic because it's part of a pattern. Sen. Daniel Akaka, D-Hawaii, ranking member of the Veterans Affairs Committee, is asking VA officials to explain how Schulze slipped through the medical system. In his letter to VA, Akaka questioned the efficacy of the bureaucracy, but he also acknowledged a deeper problem. Since the conflicts in Iraq and Afghanistan began, soldier suicides have been on the rise.

In 2003, Army troops who had served in Iraq committed suicide at a rate of 17.3 per 100,000 soldiers. That number is high compared with a historical average of 11.9 per 100,000 soldiers, according to the Senate Armed Services Committee, which used Army statistics as its benchmark. In 2005, the Pentagon's survey of mental health in all branches of the military found that 4.9 percent of service members had seriously considered suicide within the past year-that's 4,900 per 100,000 who at least thought in earnest about killing themselves.

Suicide rates are one of the most extreme examples of the ravages of combat duty, but there are others. In the southern United States, Iraq veterans' use of mental health care services, both inpatient and outpatient, rose by more than 20 percent from 2002 to 2005, according to a Defense Department analysis.

The medical community has recognized the problem as well. Two studies, one in the New England Journal of Medicine and another in the Journal of the American Medical Association, found that combat, especially in Iraq, led to more mental health problems for soldiers.

The Air Force is lucky. Less than 2 percent of airmen have been in direct combat, according to Air Force Secretary Michael W. Wynne. The Air Force has actually seen a downward trend in suicide rates over the past decade, even since the wars began. There have been no Air Force suicides in Iraq or Afghanistan.

Wynne credits this to a suicide prevention program that began in 1996. Airmen are screened for suicidal signs when they enter the service, reevaluated yearly, and checked yet again before deployment to a war zone.

Early diagnosis to prevent suicide is spreading in the military. In September, the Defense Department launched a pilot program for early diagnosis of post-traumatic stress disorder, the results of which are expected in April.

But even as senators demand answers and Defense provides more mental health services, there is another barrier. Schulze sought help and was deferred, but many soldiers never even seek treatment because of its stigmatization.

"Though it's clearly a challenge for us in the area of stigma, whether receiving mental health support would be damaging to ones' career, well over half [of soldiers surveyed] perceived that it definitely would not harm their career," says Winkenwerder. "There is some perception [that such a stigma] is nearly universal. That's clearly not the case."

That's one way of looking at it. The New England Journal of Medicine has another. Its study found that only 23 percent to 40 percent of soldiers who actually suffered from mental disorders sought help. Soldiers with mental disorders were twice as likely to think there was a stigma to seeking care as those who were mentally healthy.

Winkenwerder has another explanation. "People don't always go to a mental health professional, that is a psychiatrist or psychologist," Winkenwerder says. "They may go to a chaplain or their general physician. They go to different places to get that support."

"I was a primary care internist myself and I suspect that 20 percent of patients I saw were in because they were anxious about something," Winkenwerder says.

Wherever they go, soldiers probably will find their names will be added to long lists of soldiers seeking help, like the one at Schulze's VA center. A full 22 percent of soldiers in the 2005 Pentagon study met the criteria for depressive disorder, and 12.7 percent met the criteria for a generalized anxiety disorder.

And then there's post-traumatic stress disorder, a mental health concern more specific to war zones, though certainly not confined to them. The Minneapolis-St. Paul Star Tribune, Schulze's local newspaper, quoted his family physician, Dr. William Phillips, as being fairly certain Schulze suffered from PTSD. In the Pentagon survey, 6.7 percent of participants said they met the criteria for further examination of PTSD within the past 30 days.

Soldiers and veterans face a combination of increased suicidal tendencies, mental health care stigma and long waits, which can be overwhelming. But those in contact with them can play a critical role. The Veterans Affairs Department says watch for eight warning signs for suicide: Talking about wanting to hurt or kill oneself; trying to get pills, guns or other ways to harm oneself; talking or writing about death, dying or suicide; hopelessness, rage, uncontrolled anger and seeking revenge; acting in a reckless or risky way; feeling trapped; and saying there is no reason for living.

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